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PERSONALITY DISORDERS

This is a work in progress and will eventually include links to other posts I have written about other mental health issues. Comments are greatly appreciated!

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It seems as if mental health is a popular topic of discussion, particularly as it applies to many of our public figures. In the entertainment world, it is almost a normal line item on the resume to have emotional problems, and any outrageous and disruptive behavior (if followed by apologies and a stint in rehab) is immediately forgiven. We lament the behavior, but suck up the gossip shows and magazines, and even the news divisions of the major networks package their broadcasts for the entertainment value before our need to know. As someone trained to work with persons with disabilities, I appreciate the lessening of the stigma attached to mental illness, although I am not sure the kind of behaviors the media like to shine a light on are always particularly helpful.

Although I am trained and qualified to diagnose mental illnesses using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), I could not make a formal diagnosis of anyone without a formal evaluation. The more serious the diagnosis, the more intensive the evaluation must be.

Within the DSM-IV, there are two primary categories: 1) mood and anxiety disorders, and 2) personality disorders and mental retardation. Mood disorders are separate because they are disorders that are, theoretically at least, curable. The more we learn, the more we understand that there is very likely an organic component to mental illness. Studies are showing a genetic link to some mental illnesses; schizophrenia and ADD for example, and depression although possibly situationally caused, is a chemical as well as emotional problem. We also know, however, that regardless of any genetic or other organic factors, many mental health disorders also require a trigger or series of triggers to occur, and some disorders are diagnosed relative only to the type and duration of the trigger.

When making a diagnosis, it is possible that an individual may have more than one diagnosis on Axis I, the line used for mood disorders. If a major disorder such as schizophrenia is diagnosed, then the other mood disorders are noted only as points of information, but for treatment purposes they are subsumed within the greater disorder. An individual with Axis I diagnoses may also have a diagnosis on Axis II, the line used for mental retardation and personality disorders. Mental retardation (an IQ score of 70 or below prior to age 18 with concurrent adaptive functional disability).

A personality disorder is one of ten disorders categorized within three primary clusters. In each case, just as in all of the mood disorders (save one), there must be functional distress or impairment. On the Axis II line, we also list personality disorder traits that are significant to treatment even if they do not meet diagnostic criteria. For example, if an individual has a history of setting fires as a child, and exhibits impulse control behaviors and compulsive lying, those traits would be noted even if a diagnosis of antisocial personality disorder could not formally be made.

It should be noted that in each category of mood and personality disorders, is a category called "Not Otherwise Specified" (NOS) which is used when there is a disorder of clinical significance that does not meet the specific criteria. Most individuals with personality disorders do not meet the "official" criteria for a specific disorder but rather, fall within the cluster. Someone with a Cluster B disorder might exhibit features of antisocial behavior, narcissistic, and borderline, but not meet the criteria for any one diagnoses. Since we do not have a coding for "Cluster B" disorder, we use the NOS.

Schizotypal - acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior

Cluster B -

Antisocial - disregard for and violation of the rights of others (must be able to retroactively diagnose Conduct Disorder prior to age 15)

Borderline - a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity

Histrionic - a pattern of excessive emotionality and attention seeking

Narcissistic - a pattern of grandiosity, need for admiration, and lack of empathy

Cluster C -

Avoidant - a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation

Dependent - a pattern of submissive and clinging behavior related to an excessive need to be taken care of

Obsessive-Compulsive - a pattern of preoccupation with orderliness, perfectionism, and control

It is extremely important to understand that these are personality traits shared by almost everyone to some degree. These traits become disorders when they are enduring and related to the individual's way of perceiving and thinking about their environment and self in social and personal contexts. It is only when these traits are inflexible and maladaptive and cause significant impairment or distress that they become a personality disorder.

The other thing to remember about personality disorders, is culture. The patterns described above must be enduring, fixed, and long-term and describe behavior in two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control (Cluster A) across a broad range of personal and social situations that "deviates markedly from the expectations of the individual's culture" (p. 686, DSM-IV).

It is important that the individual's long-term pattern of functioning be evaluated. The traits that are used to diagnose a personality disorder are evident by early adulthood and cannot be confused with traits that arise from a specific situation, a mood disorder, a general medical condition, or the use or discontinued use of alcohol or drugs. Because the characteristics of personality disorders also occur within episodes of mood disorders, the defining feature of appearance before early adulthood must be present.

It is believed that personality disorders are the result of early childhood experiences, although there tend to be more men diagnosed with antisocial personality disorders and more women diagnosed with borderline, histrionic, and dependent personality disorders, it is still too early to say if social stereotypes about typical roles and behaviors play a part. The nature vs. nurture discussion is ongoing as the argument that increased rates of personality disorders within a family point to a genetic component could also equally well point to familial/cultural patterns of behavior.

My experience suggests that there is likely a genetic component affected by environmental factors. Not everyone reacts to the same stimuli in the same way which weighs strongly on the side of a genetic component, however, as a sociologist as well as a counselor, I am disinclined to ignore the influence of socialization on all aspects of growth and development. Nature and nurture, with some disorders more affected by nurture than others.